Management of Pulmonary Tuberculosis in the Private Health Sector of Pakistan

One of the findings showed thatpatients’ knowledge about their disease was minimal, and these patientsinitially went to private practitioners, who gave incorrect or limited healtheducati

BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF INTERNATIONAL HEALTH

CONCENTRATION PAPER COVER PAGE

Name: Dr Rehan Azeem (rehan_azeem@yahoo.com)

Concentration Paper Title:

MANAGEMENT OF PULMONARY TUBERCULOSIS IN THE PRIVATE HEALTH SECTOR OF PAKISTAN

Due to a personal interest in how TB is treated, I undertook a study ofknowledge, attitude, and practices (KAP) of private medical practitioners,along with TB patients and pharmacists selling TB drugs in the FederalCapital of Pakistan and its neighboring city (i.e Islamabad and Rawalpindi).

The study reflects the tip of an iceberg of weaknesses in the privatehealth sector in controlling and treating tuberculosis by examining thelinkages between private physicians, pharmacies and TB patients This paper

is intended to help policy makers in health systems, health officials, faculty

in medical institutes, non-governmental organizations and health careproviders in developing countries to understand the reasons for the poorprivate sector treatment of TB Donor agencies dealing with TB control andhigh level officials of the WHO TB Control program in Geneva will find thispaper beneficial for promoting similar studies on a bigger level

1 INTRODUCTION

TB is the leading infectious cause of death worldwide Almost twobillion people are infected around the globe (1), with 49% of the TB cases inSoutheast Asia Approximately 2.5 million people die each year of TB,while 95 % of deaths occur in developing countries (2)

WHO ranks Pakistan 6th among the 23 high burden TB countries.Based on a total population of 152 million, estimated incidence rate of all

TB cases in Pakistan is 177/100,000-population (3) The majority of 74,229registered doctors in Pakistan tend to practice in the urban areas (4, 5)

Due to a poorly managed government health infrastructure inPakistan, a large number of TB patients in both rural and urban areas visitprivate clinics run by general practitioners and consultants Among thehandful of studies done in Pakistan, 36 patients were interviewed in depthwho were attending TB clinics in rural areas of Islamabad to determine theeffects of TB on their private lives (6) One of the findings showed thatpatients’ knowledge about their disease was minimal, and these patientsinitially went to private practitioners, who gave incorrect or limited healtheducation and prescribed faulty treatment regimens

Another study done in the Indian State of Maharashtra found thatmany private doctors prescribe wrong TB drugs (7) Due to a personalinterest in how TB is treated in Pakistan, I undertook a similar study ofknowledge, attitude, and practices (KAP) of private medical practitioners,along with TB patients and pharmacists selling TB drugs in the FederalCapital of Pakistan and its neighboring city (i.e Islamabad and Rawalpindi).The study reflects the tip of an iceberg of weaknesses in the private healthsector in controlling and treating tuberculosis by examining the linkagesbetween private physicians, pharmacies and TB patients

Tuberculosis control in Pakistan is primarily the responsibility of thegovernment sector, which has been neglected for years Treatmentcompletion is low as patients are burdened with poverty and come from all

walks of life (8), the majority being unmarried women, housewives, anddaily wage laborers The National TB Programme has adopted DOTS astheir main course of action, but requires guidance on types of treatmentaccording to the local conditions (8) A randomized clinical trial at threesites in Pakistan to assess effectiveness of different packages for TBtreatment under the operational conditions proposed by the National TBControl Programme showed that the cure rates for various treatmentstrategies were between 62% to 67% as compared to the WHO guidelines(8) The pharmaceutical industry plays an important role regarding choice ofmedicines by doctors in the private and public health sectors through the use

of various incentives These pharmaceutical giants also arrange educationalseminars for doctors to update them about various treatment strategies

This paper is intended to help policy makers in health systems, healthofficials, faculty in medical institutes, non-governmental organizations andhealth care providers in developing countries to understand the reasons forthe poor private sector treatment of TB Donor agencies dealing with TBcontrol and high level officials of the WHO TB Control program in Genevawill find this paper beneficial for promoting similar studies on a bigger level

2 LITERATURE REVIEW

The purpose of the literature review was to find a correlation betweenpoor private sector treatment of TB in developing countries

Prevalence: TB infects almost one-third of the world population (1).

Of those aged over 5 years, TB kills more people than AIDS and all othertropical diseases combined (9) Ninety million new cases of TB wereexpected to occur worldwide during 1990-1999 The incidence of TB islikely to increase to 11.9 million cases annually by 2005 (2) Due toinadequacy of disease surveillance in the majority of countries the exact data

on incidence and mortality of TB cannot be projected accurately (2)

In 1993, WHO declared TB a global emergency (9) From 1994-1997the global surveillance for anti-tuberculosis drug resistance by WHO founddrug resistance in 35 countries During the current age of air travel, thisproblem could threaten the US as well (1) The developing world hosts 95%

of the eight million cases of TB reported annually Of these, 5 millionreceive some treatment, while only 0.5 million receive curative DOTS (10).WHO has warned that the annual number of deaths by 2004 could go up to 4million a year (9)

Economic Impact: Even though an effective cure has been available

for 40 years, the number of people dying each year keeps on increasing Theeconomic impact affects both the developed and the developing countries.The budget of the Bureau of TB Control of New York City Department ofHealth increased from $4 million to $ 40 million between 1988 and 1994(11) In a study done in India to assess the socioeconomic impact of TB,over 300 patients were interviewed (12) It was seen that mean total cost oftreatment projected for a six-month course was $171, while the averageperiod of loss of wages was 3 months This shows the extent of burden TBpatients and their families face in developing nations

Treatment Strategies: Two strategies proposed by different clinicians

for improving TB treatment are DOTS and re-education of private

physicians for prescribing proper treatment for TB patients (1) Theimportance of DOTS in the US and U.K is clear as it can be enforced by acourt order for non-compliant patients in both countries Incentives of freefood, clothes, transportation tokens and even financial assistance have beenused to implement DOTS (11) It should be noted that the main cause offailure of TB control is the fault of the health practitioner, therefore WHOstrongly emphasizes use of DOTS (9) It has been documented that fixeddose combinations (FDC) of TB drugs led to simplified treatment, bettercompliance, limited prescription mistakes and reduced chances of mono-therapy The combined effect can in theory limit the risk of multi-drugresistant TB (13)

Diagnostic Tools for TB include clinical examination, sputum

microscopy (specific/limited sensitivity), chest radiology specific) and culture (sensitive/long term) WHO has recommended that datacollection for TB cases should be backed by laboratory confirmedpulmonary cases (3)

(sensitive/non-Low Treatment Knowledge & Faulty Prescription Practices of Doctors: It was kept in mind during the review that the health care and

medical education system in India and Pakistan are similar to each other i.e.,British based Reviewing studies for evaluating TB treatment in the privatehealth sector in India indicated a similar scenario of faulty prescriptionpractices

Five hundred thousand Indians die from TB every year A 50%default rate in treatment points towards the non-effectiveness of the National

TB Control Program (14) The Indian Health Ministry TB Control programreports 1.5 million cases of TB every year with a mortality of 1200 patientsper day (15) A study done in Maharashtra revealed 71 faulty prescriptionsamong 100 doctors who had a post-graduate degree Over three-quarters ofthe 8 million registered doctors in India are working in private practice

Studies indicate gaps and weaknesses in the private doctors’ practice ofmanaging TB (15)

A knowledge, attitude and practice (KAP) study comprised of 40residents and faculty members from various departments prescribing TBtreatment was done in a medical institution in India (16) Only 50% ofdoctors gave correct doses in prescriptions and < 50% knew what DOTSwas The authors of the paper suggested that the faculty members should bere-educated regarding recent guidelines and trends if knowledge was topercolate to the periphery (16)

In a study done in Mumbai (India), it was found that 100 privatepractitioners prescribed 80 different regimens of anti-tuberculosis treatment,most of which were inappropriate and expensive (17) A study inMaharashtra tried to look at TB management among 122 privatepractitioners and the treatment behavior of 173 patients The resultsindicated that 79 different prescriptions were given out (18)

The treatment of TB is not possible without re-educating prospectiveand practicing clinicians around the world (1) One effective method to fightdiscrepancies in prescription practices by private practitioners would be toremove all single formulations of TB drugs from the open market and permitonly fixed dose combinations to be sold (19)

Patient Behavior: Private medical practitioners play a vital role in TB

control in Southeast Asia In Hong Kong, 159 patients with smear positiveand 187 with smear negative TB, attending Government chest clinics wereinterviewed, of them 86% initially went to a private practitioner (20).Another study in Hong Kong included 201 smear positive and 199 smearnegative TB patients The results of the study showed that a privatepractitioner was the initial choice for 53% of these patients (21) In Vietnam,

a retrospective survey of 801 TB patients in 8 District TB Units was carriedout to assess utilization of private and public health care providers for TBsymptoms Half of the patients initially went to a private practitioner (22)

Most TB patients in urban and rural parts of India initially go todoctors in the private sector (15) It is estimated that there are 10 million TBpatients in India who prefer to visit a private health practitioner afterworking hours and pay them as little as 10 rupees for a checkup (23) Astudy done in Maharashtra indicated that 86% of TB patients go to privatedoctors for their first source of treatment, while the treatment adherence rateamong these patients was 59% (18) A NGO in Mumbai studied the health-seeking behavior of poor male and female TB patients Results indicated thatduring the first two months of symptoms the patients took home remediesand then proceeded to visit private practitioners who were generally unable

to diagnose the disease (24)

Role of Pharmacies: In most parts of the world it is very common for

TB treatment to be self- administered (19) Untrained healers and patientsoften misuse TB medications, as they are available for sale over the counter(19) At the onset of initial symptoms, people tend to self prescribe drugs,rather than go to a doctor (19) A study pointing towards anti TB treatment

in 50 private pharmacies in Nepal suggested that 65% of pharmacies hadsold anti TB drugs during the last month Eighty eight percent said that only16% patients returned to buy the full course of drugs Thirty percent ofpharmacies had no doctors attached to them (25) A study conducted by aGovernment Medical College in India showed that 31% of the peopleinterviewed practiced self-medication for their illness (26) A cross sectionalstudy done in Karachi, Pakistan involving 158 households showed thatmedicines were self prescribed by 51.3% of the sample population forvarious ailments (27)

Based on this literature review, a study was undertaken in Pakistan toinvestigate the KAP of private medical practitioners, pharmacists and TBpatients to assess the reasons for poor private sector treatment of TB

3 Survey Methodology

Three different types of surveys were designed These consisted of anequal number of private doctors, private pharmacies and TB patients who atone time visited a private health practitioner for their checkup

a Survey of Private Medical Practitioners (Annex 1- A):

Thirty private practitioners were randomly selected by convenience intwo adjoining cities An equal number of general practitioners (GP) andspecialists were selected Each survey had 26 questions, which containedobservations combined with qualitative and quantitative responses Thesequestions range from characteristics of practitioners, patient interaction,knowledge of diagnostic criteria and diagnostic procedures followed,prescription practices, knowledge of causes of TB and information/adviceprovided to patients In certain cases the doctors filled in the answers to thequestions themselves rather than replying to the questions verbally

b Survey of Pharmacies (Annex 1 – B):

Thirty private pharmacies were randomly selected by convenience.Each survey had 20 questions involving qualitative and quantitative

responses Questions asked included characteristics of pharmacies, turnover

of TB medicines and their cost, knowledge held by pharmacy owners about

TB, willingness to provide TB treatment on their own, knowledge aboutDOTS and supervising treatment of a TB patient

c Survey of Patients (Annex 1 – C):

Thirty TB patients were randomly selected by convenience frommedical clinics and government hospitals around two adjoining cities Thesepatients at one time of their TB disease had visited a private medicalpractitioner Thirty questions were asked which included patientcharacteristics, duration of symptoms, time interval between onset ofsymptoms and visit to doctor, followed by diagnosis time Further questionsrevolved around cost of treatment, name/number and duration of drugs

prescribed, follow-ups to the doctor and the information/precautionsuggested by the doctor to these patients while taking TB treatment.Knowledge held by these patients about TB as a disease was alsodetermined.

One US $ equaled 55 Pakistani Rupees (Rs) when the survey wasconducted Survey questions were revised after pilot testing to accommodate

a better range of responses Data entry and construction of analysis tableswas done in Microsoft Excel Analysis of data was done by tallying data byidentifying identical sets of responses in the questionnaires Crosstabulation was done in case of similar questions asked in the three surveysubsets

4 Survey Results

a Survey of Private Medical Practitioners:

Characteristics of Practitioners: Twenty-five male and five female

private practitioners were interviewed The year of their graduation rangedfrom 1966 to 1997, with the mean graduation year of 1988 Twenty-fourwere locally qualified, out of which 12 possessed the lowest medical degree

The remaining 6 doctors were foreign qualified consultants (Table 1) The

number of years in private practice for these doctors ranged from fivemonths to 15 years, with the mean of 5.1 years The majority practiced in

rich to middle income localities (Table 2) All doctors had clinics where

they offered one sort of a diagnostic facility More than one-third had an

advanced lab facility and x-ray machine at the clinic (Table 3)

Patient Interaction: These doctors practiced from 2 hours to 10 hours

per day, with the mean of 5 hours The average fee taken by these doctorsper patient ranged from Rs 50 (US $ 0.90) to Rs.500 (US $9.09), with themean of Rs.142.06 (US $ 2.58) The average consultation time, which thesedoctors spent on their day to day patients, was observed within a range of 5

minutes to 20 minutes, with a mean of 12.4 minutes The approximatenumber of new TB patients seen per month ranged from 3 to 120, with amean of 6.3 patients per month

Knowledge of Diagnostic Criteria and Diagnostic Procedures Followed: Twenty-five doctors mentioned chronic cough as one of the

symptoms for the diagnostic criteria followed for TB, 23 mentioned fever,

while 13 pointed to weight loss (Table 4) Ten physicians mentioned

crepitations (lung sounds) as one of the signs for the diagnostic criteria

followed for TB while 8 mentioned a toxic looking patient (Table 5) Chest

X-Ray was the choice of 26 doctors as a lab test for diagnosing TB, followed

by 21 doctors who mentioned Blood Complete Picture (CP) as their choice.Fourteen doctors stated sputum AFB microscopy Culture/Sensitivity (C/S),followed by 6 responses each of Mantoux Tests and Erythrocyte

Sedimentation Rate (ESR) (Table 6) Fourteen doctors preferred Micro Dot/

Anti Dot as a special tests for diagnosing TB while 11 indicated Acid Fast

Bacilli (AFB) to be their choice (Table 7) These results contrast with the

WHO standard method of microscopic examination of sputum for AFB

Follow up Procedure: Fifteen doctors advised the TB patients to visit

them after every two weeks The method of confirmation of TB elimination

by 27 doctors was a Chest X-Ray; 17 mentioned Sputum C/S, while 12

relied on a blood CP (Table 8).

Treatment History: Fourteen doctors admitted to facing difficulties in

treating TB patients at one point of their medical career The reason forsetbacks in treatment given by these doctors was poor drug compliance

Information Provided to Patients by Doctor: Twenty-one doctors

said that they advised their patients to take TB drugs before breakfast (Table

9) The most common adverse effects of TB medication told to the patients

was the urine getting orange in color (11 responses), followed by jaundice (8

responses) (Table 10) Six doctors told their patients to avoid physical contact, while 5 warned there might be gastrointestinal discomfort (Table

11) All doctors advised their patients to have a good healthy diet while 9

physicians insisted on taking a high protein diet

Knowledge of Causes of TB: Poor diet/sanitary conditions,

overcrowding, poverty, low education, pollution, poor drug compliance,smoking and refugee settlements were blamed by these doctors to be a cause

of rise in TB cases All but 2 of the 30 doctors pinpointed the low economic groups as a major target of TB

socio-Preference of Patients: According to one-third of the private

practitioners, TB patients preferred low treatment costs and a short treatment

course (Table 12)

Practitioners ranked the level of knowledge held by TB patients

between none to low level (Table 13).

View of DOTS: Twelve doctors viewed DOTS as an excellent

approach while 3 had no knowledge of this method of treatment Twentydoctors preferred fixed dose combination tablets over individual tablets

Referral and Confidentiality: Seven private practitioners said that

they will refer their patients to a TB specialist if he/she cannot affordtreatment or if the patient has an end stage disease (6 responses) Only 2 ofthe 30 doctors stated that they notify the government when a new TB patient

comes to them for treatment (Table 14) Eight of the 30 doctors did not treat

tuberculosis as a confidential matter, i.e., they inform the family members of

a patient’s health status

Correctness of Treatment: Correct treatment method was taken as

four drugs with vitamins for intensive phase, while 2 drugs comprised ofRifampacin and Isoniazid or Isoniazid and Ethambutol for the continuationphase It was seen that the foreign qualified consultants had the most

command over proper treatment methods of TB (Table 15) Thirty-two

different types of TB prescriptions were being prescribed by these doctors,out of which only 13 were according to the WHO standards

b Survey of Pharmacies:

Characteristics of Pharmacies: Thirty pharmacy owners were

interviewed They ranged from 2 to 37 years in business with a mean of 11.6years A near equal number of pharmacies were selected according to the

areas where they were located (Table 16) The number of staff ranged from

1 to 25, with a mean of 3.8 employees per pharmacy The number ofmedicines in stock ranged from 4 to 3000 drugs with an average of 131.5.Only five pharmacies were associated with some sort of a health plan

TB Medicine Turnover: The number of generic TB drugs in stock

ranged from zero to 20, with an average of 6.6 generic drugs per pharmacy.The number of brand name TB drugs in stock ranged from 2 to 30 with anaverage of 8.43 The number of combination TB drugs in stock ranged from

2 to 29, with an average of 7.2 Twenty-three drug sellers said that thecombination products (Myrin and Myrin-P) are the most sold brand of TBdrugs, followed by Rimactane, Rimactazid, and Pyrazid The sale of theMyrin and Myrin-P was based on their high prescription by doctors and lowcost The number of packets of TB drugs sold by these pharmacies rangedfrom 1 to 50 per month with a mean of 17.2 The approximate value of drugssold ranged from Rs 295 to Rs 15,000 (US $ 5.36 to US $ 272.7), with theaverage of Rs.4010 (US $ 72.9)

Prescription Practices: As reported by 28 pharmacy owners, based on

a percentage of TB drug procurement, 5.2% of the drugs were selfprescribed, 35.2% were prescribed by doctors, 46.5% were traced to patients

in hospitals and 1.6% were purchase by traditional healers Fifteenpharmacists reported that patients were not comfortable with TB drug prices,while 1 pharmacy owner had no idea

Knowledge about TB: Sixteen pharmacy owners knew nothing about

the mode of transmission of TB Eleven attributed the spread of TB tocoughing Only 12 pharmacy owners could answer correctly that TB was notcongenital All the drug sellers pointed towards good health as the outcome

of proper treatment for tuberculosis Sixteen pharmacy owners said deathwas a probable outcome without treatment for tuberculosis As to outcome

of incomplete treatment, 13 said that the disease re-occurs, while 8 repliedthat the disease increases

Willingness to Provide TB Medications: Twenty-one pharmacy

owners declined to provide TB treatment over the counter to patients Threehad no idea what treatment they could provide, even if asked The rest gave

inappropriate treatment methodologies (Table 17).

Advice Given to Patients: Twenty-four pharmacists said that while

selling drugs to TB patients, they advised them to take medicines according

to their doctor’s instructions

Treatment of Chronic Cough: Eighteen pharmacy owners declined to

manage a patient with chronic cough However, 10 pharmacists would givecough syrup to a patient with chronic cough

Patient’s Knowledge of TB: Twelve pharmacy owners said that the

public had low/minimal knowledge of TB,

Drug Compliance: Eighteen pharmacy owners blamed economic and

financial problems of the masses for discontinuation of treatment Seven

pharmacists did not see any breaks in the course of treatment of TB patients.The remainder suggested that the patients might have changed theirresidence or started buying medicines from another shop

Knowledge of DOTS/Supervision of Treatment of TB Patient: None

of the pharmacy owners had ever heard about DOTS Twenty-six declined tosupervise a TB patient to take drugs if paid in advance When explained theconcept of DOTS, majority of the pharmacy owners agreed to supervisetreatment of TB patients if they had an incentive of a cash bonus rangingfrom 5-10% of the whole treatment cost for tuberculosis

c Survey of Patients:

Characteristics of Patients: Thirty TB patients were interviewed

whose age ranged from 9 to 67 years with the mean age of 55 Sixteen weremen, while half of the patients were married The number of dependentsranged from zero to 8, bringing the average number of dependents to 2.6 perpatient The average monthly family income ranges from Rs.2000 toRs.40000 (US $ 36.6 to US $ 727.7) Five patients did not know theiraverage monthly income The mean monthly family income came toRs.5260 (US $ 95.6) Thirteen patients were associated with some sort ofhealth plan Seventeen patients had a source of income, which they earnedthemselves; the rest were dependent on other people of their household.Nineteen patients were non-smokers and 8 were smokers The duration ofsmoking in the patients who smoked ranged from 2.5 to 50 years, with theaverage of 19.5

Duration of Symptoms: Twenty-five patients had a history of cough,

which ranged from 1month in duration to 10 years, average being 8.6months Twenty-five patients had a history of a productive cough, whichranged from one month to 10 years, average being 8.16 months Only 7patients had an initial history of haemoptysis, with a range of 6 days to 6months, with a mean of 2.2 months Twenty-four patients complained ofhaving a fever, range being 15 days to 15 months with a mean of 2.2months Eight patients complained of night sweats, with duration of oneweek to 15 months, mean duration being 3.4 months

Intervals: The time interval between onset of symptoms and visit to

doctor ranged between 2 days to 7 months, with the mean of 1.5 months.The time interval between the first visit to a doctor and diagnosis rangedbetween zero days and 5 months, with the mean of 0.53 months

Health Seeking Behavior of Patients: All but one patient went

initially to a general practitioner for the treatment of TB Nine patients chosethe type of health facility visited initially for its good reputation Eight

patients went to the facility because it provided them with free medicines, 6because of low costs, while for the rest it was either the site of a familydoctor or it was easy for them to go after work.

Costs: The treatment cost for first consultation for TB ranged from

free services to Rs.500 (US $ 9.09) The average amount paid was Rs.120.80(US $ 2.19) The treatment cost before diagnosis ranged from Rs.25 toRs.5000 (Us $ 0.5 to US $ 90.9) Ten patients did not have any idea of howmuch it cost The total cost of the therapy ranged from Rs.1000 to Rs.8000(US $ 18.18 to US $ 145.4) Twenty-one patients had no idea what the totalcost of therapy was; the average cost came to about Rs.4222.20 (US $76.76)

Lab Investigations Done: All but one patient initially had a chest

X-Ray, 24 had a blood test, while 20 had sputum microscopy C/S test Sevenpatients had a urine test

Prescription Practices: The number of drugs prescribed for

tuberculosis at diagnosis ranged from 2 to 8 drugs with an average of 3.8 TBdrugs prescribed per patients Twenty-six patients were still on TB drugs

The range was between 1 to 4 drugs, the average being 2.8 drugs Table 18

shows the names of the drugs prescribed to these patients and the number oftimes they were repeated among the prescriptions The duration of treatmentadvised to these patients ranged from 1 month to 1 year The averageduration of treatment advised to patients was 6 months

Follow-up: Twenty-three patients could not remember the interval

after diagnosis and prescription of medicines linked with the follow-up ofthe doctor For the remainder of the patients, the duration ranged from1week to 2 months, with a mean duration of 4 weeks Twenty-nine patientshad a chest X-Ray at the follow up, 20 had a blood CP, while 15 had sputum

C/S (Table 19) Ten patients could not remember the total number of

follow-up visits they had The range for the ones that remembered liesbetween 1 and 10, with an average of 5

Drug Compliance: The duration of compliance ranged from 45 days

to 12 months, with a mean of 3.3 months Nine patients reported breaks intheir treatment Four patients blamed the medicines being expensive for non-compliance while 3 said that there were too many tablets

Knowledge of Patients about TB: Eleven patients had no knowledge

of TB as a disease, while 14 had low knowledge The doctor orfriends/family members commonly provided information about TB Themedia played the role of a learning channel for 6 patients

Information Given by Doctor about Contacts: Fourteen patients were

not provided with any information by the doctor about contacts duringtreatment Ten patients were told to avoid contact with friends, family andchildren Four patients were told to cover their mouth while coughing, andfour were told to have separate towels and utensils Keeping in mind that it

is very important to complete the entire treatment for TB, only 2 patientswere told to complete the entire course

TB Patient’s Preferences: Most TB patients suggested that they want

a limited drug course with a preference towards fewer medicines Betterhealth plans to lower cost of treatment were needed TB patients wanted thatpreference should be given to women, children and old patients duringtreatment

5 DISCUSSION:

Doctors: The literature review and the data gathered by this survey

have many similarities Private physicians in Pakistan are no different thantheir counterparts in various cities in India Provided that the average visit to

a private practitioner costs less than U.S $3, they base their practices ongetting a high number of investigations done per patient in their own clinicalsetup An average of 6.3 new patients per month visits each of these doctors.The consultants examined the patients for an average of 15 minutes

compared to 5 minutes by the GPs The survey showed that consultants hadthe ability to properly diagnose and treat TB; this might be due to the bettermedical training that they had Unfortunately the number of such doctors inPakistan is low The majority of the doctors surveyed were not able topinpoint proper diagnostic criteria and procedures and were unclear in thedifferentiation of special lab tests for diagnosing TB Most assessedelimination of disease during follow up on chest x-rays, instead of sputummicroscopy While I reviewed the prescriptions given to TB patients, it wasclear that there was no rationale for the various treatment regimes TB drugswere being prescribed in high, unnecessary and sometimes duplicate doses.Patients were told to take the TB drugs before breakfast by a majority ofdoctors but only six doctors indicated during the surveys that they told theirpatients to avoid physical contact with their families All doctors had a goodknowledge about the cause of TB, and were aware of the preferences of thepatients regarding a short and inexpensive course of therapy for TB DOTSwas not viewed as an approach of choice by most physicians At the sametime the majority of the doctors preferred to use fixed dose combinations.This was evident from the survey of pharmacies, during which it was seenthat private practitioners most commonly prescribe Myrin and Myrin P,which are fixed dose combinations It was shocking to note that only 2doctors among the 30 interviewed were in the habit of reporting new TBcases to the government

Pharmacies: Nearly all pharmacies surveyed had an adequate stock of

both generic and brand name TB drugs Sales of fixed dose combinationpills were highest in most cases The owners attributed this to theprescription practices of doctors and the low price of the drugs According tothem most patients were not comfortable about the price of TB drugs It wasnoted that the majority of pharmacy owners reported not providing any sort

of treatment to a TB patient or to a patient with chronic cough They alsorefrained from giving any advice to the patient apart from what was written

in the doctor’s prescription These may have been biased responses To test

whether this is actually the case, a “mystery patient” (28) could be used Thepharmacists had poor knowledge about the transmission of TB None hadheard about DOTS, but when given an explanation about the idea, weremore than willing to monitor treatment provided they got to earn somepercentage (5% to 10%) of the total cost of therapy.

Patients: The majority of TB patients interviewed in this study went

to a private health practitioner initially for their checkup These patientswere randomly surveyed by visiting health clinics, government hospitaloutpatient departments and TB centers Though nearly half of the patientshad some sort of health plan, only 5 pharmacies supported such patients Theduration of symptoms was longer than the interval between onset ofsymptoms and first visit to a doctor This shows that these patients wereseeking alternative methods of relief of symptoms rather than going to adoctor Nevertheless it took nearly a month for a TB patient to be diagnosedfrom the time he/she first visited the doctor This behavior can be linked tothe fact that the mean monthly family income noted was Rs 5260 (US $95.60), while the average cost of treatment of TB was Rs 4222 (US $ 76.76)and most patients could not afford it All patients had a chest X-Ray done atfollow-up, while only 20 had a sputum microscopy There was nocorrelation between number of drugs prescribed to these patients, clinicaltests done or follow up visits advised Only two of the patients surveyedwere told to complete their drug course Poor drug compliance by patientswas evident by all survey results Economic conditions, financial problemsand high cost of TB drugs were blamed Patients’ knowledge was minimalabout TB This was indicated by questions asked from doctors, pharmacyowners and TB patients themselves This could be blamed on governmentinformation channels, doctors and pharmacy owners for not providing thepatients with the required information

Study Limitations: Many doctors were not willing to answer all the

questions or fill out the survey forms as it required 20 minutes during peakpatient hours at their clinics Forms had to be left with them and collected